Do you experience any of the following symptoms? (Please check all that apply)

 Dull, burning, or sharp pain Pain in a single point in your back Pain over a broad area Pain that occurs gradually or suddenly Pain in your legs, such as numbness or tingling

Are you currently taking medication for your pain?
 Yes No

If so, what medication(s) are you taking?

Do you have a history of any of the following?

 Seizure Disorder Stroke Head Injury Brain Tumor Cancer NONE

What is your Gender?
 Male Female

Are you over 18?
 Yes No

Your Name (First and Last):

Phone:

Email Address:

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What is the best time to contact you?

How did you hear about us?
 Referral Flyer/Brochure Radio TV Web Advertisement Internet Search Facebook Previous Patient

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